Statin Therapy for the Prevention and Treatment of Cardiovascular Disease 4.3.000

Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: 
*Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR 
*Adults aged >= 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR 
*Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL

Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. PCPI disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2019 American Medical Association. LOINC(R) is copyright 2004-2019 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2019 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2019 World Health Organization. All Rights Reserved.

These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R].

This measure is intended to have one reporting rate, which aggregates the following populations into a single performance rate for reporting purposes: 

Population 1: Patients aged >= 21 years at the beginning of the measurement period with clinical ASCVD

Population 2: Patients aged >= 21 years at the beginning of the measurement period who have ever had a fasting or direct laboratory test result of LDL-C >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia

Population 3: Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with a LDL-C result of 70 -189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period
For the purposes of this measure, a single performance rate can be calculated as follows:

Performance Rate = (Numerator 1 + Numerator 2 +Numerator 3)/ [(Denominator 1 - Denominator Exclusions 1- Denominator Exceptions 1) + (Denominator 2 - Denominator Exclusions 2 - Denominator Exceptions 2) +(Denominator 3 - Denominator Exclusions 3 - Denominator Exceptions 3)]

"Cardiovascular disease (CVD) is the leading cause of death in the United States, causing approximately 1 of every 3 deaths in the United States in 2015. In 2015, stroke caused approximately 1 of every 19 deaths in the United States and the estimated annual costs for CVD and stroke were $329.7 billion, including $199.2 billion in direct costs (hospital services, physicians and other professionals, prescribed medications, home health care, and other medical durables) and $130.5 billion in indirect costs from lost future productivity (cardiovascular and stroke premature deaths). CVD costs more than any other diagnostic group" (Benjamin et al., 2018).

Data collected between 2011 and 2014 indicates that more than 94.6 million U.S. adults, 20 years or older, had total cholesterol levels equal to 200 mg/dL or more, while almost 28.5 million had levels 240 mg/dL or more (Benjamin et al., 2018). Elevated blood cholesterol is a major risk factor for CVD and statin therapy has been associated with a reduced risk of CVD. Numerous randomized trials have demonstrated that treatment with a statin reduces LDL-C, and reduces the risk of major cardiovascular events by approximately 20 percent (Ference, 2015).

In 2013, guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults were published (see Stone et al., 2014). This guideline was published by an Expert Panel, which synthesized evidence from randomized controlled trials to identify people most likely to benefit from cholesterol-lowering therapy. The American College of Cardiology (ACC)/American Heart Association (AHA) Guideline recommendations are intended to provide a strong evidence-based foundation for the treatment of blood cholesterol for the primary and secondary prevention and treatment of Atherosclerotic Cardiovascular Disease (ASCVD) in adult men and women (21 years of age or older). The document concludes the addition of statin therapy reduces the risk of ASCVD among high-risk individuals, defined as follows: individuals with clinical ASCVD, with LDL-C >= 190 mg/dL, or with diabetes and LDL-C 70-189 mg/dL (Stone et al., 2014).

One study that surveyed U.S. cardiology, primary care, and endocrinology practices found that 1 in 4 guideline-eligible patients were not on a statin and less than half were on the recommended statin intensity. Untreated and undertreated patients had significantly higher LDL-C levels than those receiving guideline-directed statin treatment (Navar et al., 2017). The Statin Safety Expert Panel that participated in an NLA Statin Safety Task Force meeting in October 2013 reaffirms the general safety of statin therapy.

However, 1 in 10 people who try taking a statin will report some kind of intolerance, most commonly muscle aches. Other known low risk circumstances of statin intolerance include side effects such as myopathy, cognitive dysfunction, increased hepatic transaminase levels, and new onset diabetes. Statin intolerance usually does not involve substantial risk for mortality or permanent disability (Guyton et al., 2014). Ultimately, the panel members concluded that for most patients requiring statin therapy, the potential benefits of statin therapy outweigh the potential risks. In general terms, the benefits of statins to prevent non-fatal myocardial infarction, revascularization, stroke, and CVD mortality, far outweighs any potential harm related to the drug (Jacobson, 2014).

This electronic clinical quality measure is intended to align with the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol (Stone et al., 2014), which indicates the use of statins as the first line of cholesterol-lowering medication therapy to lower the risk of ASCVD among at-risk populations.

Recommendations for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults - Statin Treatment:
Secondary Prevention:
1. High-intensity statin therapy should be initiated or continued as first-line therapy in women and men <=75 years of age who have clinical ASCVD, unless contraindicated. (Level of Evidence A), (Stone et al., 2014)  

2. In individuals with clinical ASCVD in whom high-intensity statin therapy would otherwise be used, when high-intensity statin therapy is contraindicated or when characteristics predisposing to statin-associated adverse effects are present, moderate-intensity statin should be used as the second option, if tolerated. (Level of Evidence A), (Stone et al., 2014) 

Primary Prevention in Individuals >= 21 Years of Age With LDL-C >=190 mg/dL:
2. Adults >=21 years of age with primary LDL-C >=190 mg/dL should be treated with statin therapy. (10-year ASCVD risk estimation is not required.) (Level of Evidence B), (Stone et al., 2014)

Primary Prevention in Individuals With Diabetes and LDL-C 70-189 mg/dL:
1. Moderate-intensity statin therapy should be initiated or continued for adults 40-75 years of age with diabetes. (Level of Evidence A), (Stone et al., 2014)

Higher score indicates better quality

Banach, M., Rizzo, M., Toth, P.,Famier M., Davidson M. H., Al-Rasadi, K., …Mikhailidis, D. P. (2015). Statin intolerance: An attempt at a unified definition. Position paper from an International Lipid Expert Panel. Archives of Medical Science, 11(1), 1-23. doi: 10.5114/aoms.2015.49807

Benjamin, E. J., Virani, S. S., Callaway, C. W., Chamberlain, A. M., Chang, A. R., Cheng, S., …Munter, P. (2018). Heart disease and stroke statistics—2018 update: A report from the American Heart Association. Circulation, 137(12), e67-e492. doi.10.1161/CIR.0000000000000558

Ference, B.A. (2015, March 10). Statins and the risk of developing new-onset Type 2 diabetes: Expert analysis. Retrieved from https://www.acc.org/latest-in-cardiology/articles/2015/03/10/08/10/statins-and-the-risk-of-developing-new-onset-type-2-diabetes

Guyton, J. R., Bays, H. E., Grundy, S. M., Jacobson, T. A. (2014). As assessment by the Statin Intolerance Panel: 2014 update. Journal of Clinical Lipidology, 8(3 Suppl.), S79. doi/10.1016/jacl.2014.03.002

Jacobson, T. A. (2014). Executive summary: NLA Task Force on Statin Safety—2014 update. Journal of Clinical Lipidology, 8(3 Suppl.), S1-S4. doi:10.1016/jacl.2014.03.002

Maddox, T. M., Borden, W. B., Tang, F., Virani, S. S., Oetgen, W. J., Mullen, B., …Rumsfeld, J. S. (2014). Implications of the 2013 ACC/AHA cholesterol guidelines for adults in contemporary cardiovascular practice: insights from the NCDR Pinnacle Registry. Journal of American College of Cardiology, 64(21), 2183-2192. doi:10.1016/j.acc.2014.08.041

Navar, M., Wang, T. Y., Li, S.,Robinson, J. G., Goldberg, A. C., Virani, S., …Peterson, E. D. (2017). Lipid management in contemporary community practice: Results from the Provider Assessment of Lipid Management (PALM) Registry. American Heart Journal, 193, 84-92. doi.10.1016/j.ahj.2017.08.005

Stone, N. J., Robinson, J., Lichtenstein, A. H., Bairey Merz, C., Blum, C. B., Eckel, R. H., …Wilson, P. W. (2014). 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Circulation, 129(25, Suppl. 2), S1-S45. doi.10.1161/01.cir.0000437738.63853.7a

Clinical atherosclerotic cardiovascular disease (ASCVD) includes: 
*  Acute coronary syndromes 
*  History of myocardial infarction 
*  Stable or unstable angina 
*  Coronary or other arterial revascularization 
*  Stroke or transient ischemic attack (TIA) 
*  Peripheral arterial disease of atherosclerotic origin 

Lipoprotein density cholesterol (LDL-C) result: 
*  A fasting or direct LDL-C laboratory test performed and test result documented in the medical record. 

Statin therapy:   
*  Administration of one or more of a group of medications that are used to lower plasma lipoprotein levels in the treatment of hyperlipoproteinemia. 

Statin Medication Therapy List (NOTE: List does NOT include dosage):

[Generic name] (Brand or trade name) and (-) Medication type, if applicable:
[Atorvastatin] (Lipitor) - Statin
[Fluvastatin] (Lescol XL or Lescol) - Statin
[Lovastatin (Mevinolin)](Mevacor or Altoprev) -Statin
[Pitavastatin]Livalo
[Pravastatin Sodium] (Pravachol) - Statin
[Rosuvastatin Calcium] (Crestor) - Statin
[Simvastatin] (Zocor) - Statin
[Amlodipine Besylate/Atorvastatin Calcium] (Caduet) - Combination
[Ezetimibe/Simvastatin] (Vytorin) - Combination

Some patients may not be appropriate to prescribe or use statin therapy (see
exceptions and exclusions for a complete list). 

"Statin intolerance is the inability to tolerate a dose of statin required to reduce a person's CV risk sufficiently from their baseline risk and could result from different statin related side effects including: muscle symptoms, headache, sleep disorders, dyspepsia, nausea, rash, alopecia, erectile dysfunction, gynecomastia, and/or arthritis" (Banach et al., 2015, p.2 ).

Patients that experience symptoms such as these may prefer not to take or continue statin therapy and therefore may be exempt from the denominator.

Numerator instructions and guidance:
-Current statin therapy use must be documented in the patient's current medication list or ordered during the measurement period.
-ONLY statin therapy meets the measure Numerator criteria (NOT other cholesterol lowering medications).
-Prescription or order does NOT need to be linked to an encounter or visit; it may be called to the pharmacy.
-Statin medication "samples" provided to patients can be documented as "current statin therapy" if documented in the medication list in health/medical record.
-Patients who meet the denominator criteria for inclusion, but are not prescribed or using statin therapy, will NOT meet performance for this measure. There is only one performance rate calculated for this measure; the weighted average of the three populations.  
-Adherence to statin therapy is not calculated in this measure.

Denominator Guidance: 
The denominator covers three distinct populations. Use the following process to prevent counting patients more than once.

Denominator Population 1:  
Patients aged >= 21 years at the beginning of the measurement period with clinical ASCVD

-If YES, meets Denominator Population 1 risk category		 
-If NO, screen for next risk category

Denominator Population 2: 
Patients aged >= 21 years at the beginning of the measurement period who have ever had a fasting or direct laboratory test result of LDL-C >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia

-If YES, meets Denominator Population 2 risk category		 
-If NO, screen for next risk category

Denominator Population 3:
Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with a LDL-C result of 70 -189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period

-If YES, meets Denominator Population 3 risk category
-If NO, patient does NOT meet Denominator criteria and is NOT eligible for measure inclusion

Denominator Guidance for Encounter:
-In order for the patient to be included in the denominator, the patient must have ONE denominator-eligible visit, defined as follows:

--Outpatient encounter visit type
--Encounter, performed: initial or established office visit, face-to-face interaction, preventive care services, or annual wellness visit

LDL-C Laboratory test result options:
The measure can be reported for all patients with a documented fasting or direct LDL-C level recorded as follows:

To meet Denominator Population 1: 
There is no LDL-C result required.

To meet Denominator Population 2:
If a patient has ANY previous fasting or direct laboratory result of LDL-C >= 190 mg/dL, report the highest value >= 190 mg/dL.

To meet Denominator Population 3: 
If a patient has more than one LDL-C result during the measurement period or during the two years before the start of the measurement period, report the highest level recorded during either time. The Denominator Exception, "Patients with diabetes who have the most recent fasting or direct LDL-C laboratory test result < 70 mg/dL and are not taking statin therapy" applies only to Denominator Population 3.

Intensity of statin therapy in primary and secondary prevention:

The expert panel of the 2013 ACC/AHA Guidelines (Stone et al., 2014) defines recommended intensity of statin therapy on the basis of the average expected LDL-C response to specific statin and dose. Although intensity of statin therapy is important in managing cholesterol, this measure assesses prescription of ANY statin therapy, irrespective of intensity. Assessment of appropriate intensity and dosage documentation added too much complexity to allow inclusion of statin therapy intensity in the measure at this time.

Lifestyle modification coaching:
A healthy lifestyle is important for the prevention of cardiovascular disease. However, lifestyle modification monitoring and documentation added too much complexity to allow its inclusion in the measure at this time.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

All patients aged 21 years and older at the beginning of the measurement period with a patient encounter during the measurement period

All patients who meet one or more of the following criteria (considered at "high risk" for cardiovascular events, under ACC/AHA guidelines):

1) Patients aged >= 21 years at the beginning of the measurement period with clinical ASCVD diagnosis 

2) Patients aged >= 21 years at the beginning of the measurement period who have ever had a fasting or direct laboratory result of LDL-C >=190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia 

3) Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with an LDL-C result of 70-189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period

Patients who have a diagnosis of pregnancy
Patients who are breastfeeding
Patients who have a diagnosis of rhabdomyolysis

Patients who are actively using or who receive an order (prescription) for statin therapy at any point during the measurement period

Patients with adverse effect, allergy, or intolerance to statin medication
Patients who are receiving palliative or hospice care
Patients with active liver disease or hepatic disease or insufficiency
Patients with end-stage renal disease (ESRD)
Patients with diabetes who have the most recent fasting or direct LDL-C laboratory test result < 70 mg/dL and are not taking statin therapy

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Population Criteria 1

Initial Population

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 21
)
  and exists "Qualifying Encounter During Measurement Period"

Denominator

"Initial Population"
  and exists "ASCVD Diagnosis or Procedure Before End of Measurement Period"

Denominator Exclusions

exists ( ( ["Diagnosis": "Rhabdomyolysis"]
    union ["Diagnosis": "Breastfeeding"]
    union ["Diagnosis": "Pregnancy or Other Related Diagnoses"] ) ExclusionDiagnosis
    where ExclusionDiagnosis.prevalencePeriod overlaps "Measurement Period"
)

Numerator

exists "Statin Therapy Ordered During Measurement Period"
  or exists "Currently Taking Statin Therapy Through the End of the Measurement Period"

- Numerator Exclusions
  - None

Denominator Exceptions

"Patient Has Order for or Receiving Hospice Care or Palliative Care"
  or "Has ESRD"
  or "Has Hepatitis or Liver Disease"
  or exists "Adverse Reaction to Statin"
  or exists "Allergy or Intolerance to Statin"

- Stratification
  - None

Population Criteria 2

Initial Population

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 21
)
  and exists "Qualifying Encounter During Measurement Period"

Denominator

"Initial Population"
  and ( exists "Current or Prior LDL Result Greater Than or Equal To 190"
      or "Has Hypercholesterolemia"
  )
  and not exists "ASCVD Diagnosis or Procedure Before End of Measurement Period"

Denominator Exclusions

exists ( ( ["Diagnosis": "Rhabdomyolysis"]
    union ["Diagnosis": "Breastfeeding"]
    union ["Diagnosis": "Pregnancy or Other Related Diagnoses"] ) ExclusionDiagnosis
    where ExclusionDiagnosis.prevalencePeriod overlaps "Measurement Period"
)

Numerator

exists "Statin Therapy Ordered During Measurement Period"
  or exists "Currently Taking Statin Therapy Through the End of the Measurement Period"

- Numerator Exclusions
  - None

Denominator Exceptions

"Patient Has Order for or Receiving Hospice Care or Palliative Care"
  or "Has ESRD"
  or "Has Hepatitis or Liver Disease"
  or exists "Adverse Reaction to Statin"
  or exists "Allergy or Intolerance to Statin"

- Stratification
  - None

Population Criteria 3

Initial Population

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 21
)
  and exists "Qualifying Encounter During Measurement Period"

Denominator

"Initial Population"
  and exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
      where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 40
        and Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) <= 75
  )
  and "Has Diabetes"
  and "Highest LDL Result Within 3 Years is Greater Than or Equal To 70 and Less Than 190" is not null
  and not exists "ASCVD Diagnosis or Procedure Before End of Measurement Period"
  and not exists "Current or Prior LDL Result Greater Than or Equal To 190"
  and not "Has Hypercholesterolemia"

Denominator Exclusions

exists ( ( ["Diagnosis": "Rhabdomyolysis"]
    union ["Diagnosis": "Breastfeeding"]
    union ["Diagnosis": "Pregnancy or Other Related Diagnoses"] ) ExclusionDiagnosis
    where ExclusionDiagnosis.prevalencePeriod overlaps "Measurement Period"
)

Numerator

exists "Statin Therapy Ordered During Measurement Period"
  or exists "Currently Taking Statin Therapy Through the End of the Measurement Period"

- Numerator Exclusions
  - None

Denominator Exceptions

"Patient Has Order for or Receiving Hospice Care or Palliative Care"
  or "Has ESRD"
  or "Has Hepatitis or Liver Disease"
  or exists "Adverse Reaction to Statin"
  or exists "Allergy or Intolerance to Statin"
  or "Most Recent LDL Result Within 3 Years is Less Than 70"

- Stratification
  - None

Adverse Reaction to Statin

["Adverse Event": "Statin Allergen"] StatinReaction
  where StatinReaction.relevantDatetime during "Measurement Period"

Allergy or Intolerance to Statin

["Allergy/Intolerance": "Statin Allergen"] StatinAllergyIntolerance
  where StatinAllergyIntolerance.prevalencePeriod overlaps "Measurement Period"

ASCVD Diagnosis or Procedure Before End of Measurement Period

( ( ["Diagnosis": "Myocardial Infarction"]
    union ["Diagnosis": "Cerebrovascular Disease, Stroke, TIA"]
    union ["Diagnosis": "Atherosclerosis and Peripheral Arterial Disease"]
    union ["Diagnosis": "Ischemic Heart Disease or Other Related Diagnoses"]
    union ["Diagnosis": "Stable and Unstable Angina"] ) ASCVDDiagnosis
    where ASCVDDiagnosis.prevalencePeriod starts before 
    end of "Measurement Period"
)
  union ( ( ["Procedure, Performed": "PCI"]
      union ["Procedure, Performed": "CABG Surgeries"]
      union ["Procedure, Performed": "Carotid Intervention"]
      union ["Procedure, Performed": "CABG, PCI Procedure"] ) ASCVDProcedure
      where ASCVDProcedure.relevantPeriod starts before 
      end of "Measurement Period"
  )

Current or Prior LDL Result Greater Than or Equal To 190

["Laboratory Test, Performed": "LDL Cholesterol"] LDL
  where LDL.result >= 190 'mg/dL'
    and LDL.relevantDatetime before 
    end of "Measurement Period"

Currently Taking Statin Therapy Through the End of the Measurement Period

( ["Medication, Active": "Low Intensity Statin Therapy"]
  union ["Medication, Active": "Moderate Intensity Statin Therapy"]
  union ["Medication, Active": "High Intensity Statin Therapy"] ) ActiveStatin
  where ActiveStatin.relevantPeriod overlaps after "Measurement Period"

Denominator 1

"Initial Population"
  and exists "ASCVD Diagnosis or Procedure Before End of Measurement Period"

Denominator 2

"Initial Population"
  and ( exists "Current or Prior LDL Result Greater Than or Equal To 190"
      or "Has Hypercholesterolemia"
  )
  and not exists "ASCVD Diagnosis or Procedure Before End of Measurement Period"

Denominator 3

"Initial Population"
  and exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
      where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 40
        and Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) <= 75
  )
  and "Has Diabetes"
  and "Highest LDL Result Within 3 Years is Greater Than or Equal To 70 and Less Than 190" is not null
  and not exists "ASCVD Diagnosis or Procedure Before End of Measurement Period"
  and not exists "Current or Prior LDL Result Greater Than or Equal To 190"
  and not "Has Hypercholesterolemia"

Denominator Exceptions

"Patient Has Order for or Receiving Hospice Care or Palliative Care"
  or "Has ESRD"
  or "Has Hepatitis or Liver Disease"
  or exists "Adverse Reaction to Statin"
  or exists "Allergy or Intolerance to Statin"

Denominator Exceptions 3

"Patient Has Order for or Receiving Hospice Care or Palliative Care"
  or "Has ESRD"
  or "Has Hepatitis or Liver Disease"
  or exists "Adverse Reaction to Statin"
  or exists "Allergy or Intolerance to Statin"
  or "Most Recent LDL Result Within 3 Years is Less Than 70"

Denominator Exclusions

exists ( ( ["Diagnosis": "Rhabdomyolysis"]
    union ["Diagnosis": "Breastfeeding"]
    union ["Diagnosis": "Pregnancy or Other Related Diagnoses"] ) ExclusionDiagnosis
    where ExclusionDiagnosis.prevalencePeriod overlaps "Measurement Period"
)

Has Diabetes

exists ( ["Diagnosis": "Diabetes"] Diabetes
    where Diabetes.prevalencePeriod overlaps "Measurement Period"
)

Has ESRD

exists ( ["Diagnosis": "End Stage Renal Disease"] ESRD
    where ESRD.prevalencePeriod overlaps "Measurement Period"
)

Has Hepatitis or Liver Disease

exists ( ( ["Diagnosis": "Hepatitis A"]
    union ["Diagnosis": "Hepatitis B"]
    union ["Diagnosis": "Liver Disease"] ) HepatitisLiverDisease
    where HepatitisLiverDisease.prevalencePeriod overlaps "Measurement Period"
)

Has Hypercholesterolemia

exists ( ["Diagnosis": "Hypercholesterolemia"] Hypercholesterolemia
    where Hypercholesterolemia.prevalencePeriod starts before 
    end of "Measurement Period"
)

Highest LDL Result Within 3 Years is Greater Than or Equal To 70 and Less Than 190

( Max(["Laboratory Test, Performed": "LDL Cholesterol"] LDL
    where LDL.relevantDatetime 3 years or less before 
    end of "Measurement Period"
    return LDL.result as Quantity
)) LDLResult
  where LDLResult in Interval[70 'mg/dL', 190 'mg/dL' )

Initial Population

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate
    where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 21
)
  and exists "Qualifying Encounter During Measurement Period"

Most Recent LDL Result Within 3 Years is Less Than 70

( Last(["Laboratory Test, Performed": "LDL Cholesterol"] LDL
    where LDL.relevantDatetime 3 years or less before 
    end "Measurement Period"
    sort by relevantDatetime
)) MostRecentLDL
  return MostRecentLDL.result < 70 'mg/dL'

Numerator

exists "Statin Therapy Ordered During Measurement Period"
  or exists "Currently Taking Statin Therapy Through the End of the Measurement Period"

Patient Has Order for or Receiving Hospice Care or Palliative Care

exists ( ( ["Intervention, Order": "Hospice Care Ambulatory"]
    union ["Intervention, Order": "Palliative or Hospice Care"] ) PalliativeOrHospiceCareOrder
    where PalliativeOrHospiceCareOrder.authorDatetime on or before 
    end of "Measurement Period"
)
  or exists ( ( ["Intervention, Performed": "Hospice Care Ambulatory"]
      union ["Intervention, Performed": "Palliative or Hospice Care"]
      union ["Encounter, Performed": "Encounter for palliative care"] ) PalliativeOrHospiceCarePerformed
      where PalliativeOrHospiceCarePerformed.relevantPeriod starts on or before 
      end of "Measurement Period"
  )

Qualifying Encounter During Measurement Period

( ["Encounter, Performed": "Annual Wellness Visit"]
  union ["Encounter, Performed": "Office Visit"]
  union ["Encounter, Performed": "Outpatient Consultation"]
  union ["Encounter, Performed": "Outpatient Encounters for Preventive Care"]
  union ["Encounter, Performed": "Preventive Care Services - Established Office Visit, 18 and Up"]
  union ["Encounter, Performed": "Preventive Care Services - Other"]
  union ["Encounter, Performed": "Preventive Care Services-Individual Counseling"]
  union ["Encounter, Performed": "Preventive Care Services-Initial Office Visit, 18 and Up"] ) ValidEncounter
  where ValidEncounter.relevantPeriod during "Measurement Period"

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Statin Therapy Ordered During Measurement Period

( ["Medication, Order": "Low Intensity Statin Therapy"]
  union ["Medication, Order": "Moderate Intensity Statin Therapy"]
  union ["Medication, Order": "High Intensity Statin Therapy"] ) StatinOrdered
  where StatinOrdered.authorDatetime during "Measurement Period"

Global.CalendarAgeInYearsAt(BirthDateTime DateTime, AsOf DateTime)
- - years between ToDate(BirthDateTime)and ToDate(AsOf)

Global.ToDate(Value DateTime)

DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)

Terminology

code "Birth date" ("LOINC Code (21112-8)")
code "Encounter for palliative care" ("ICD10CM Code (Z51.5)")
valueset "Annual Wellness Visit" (2.16.840.1.113883.3.526.3.1240)
valueset "Atherosclerosis and Peripheral Arterial Disease" (2.16.840.1.113762.1.4.1047.21)
valueset "Breastfeeding" (2.16.840.1.113762.1.4.1047.73)
valueset "CABG Surgeries" (2.16.840.1.113883.3.666.5.694)
valueset "CABG, PCI Procedure" (2.16.840.1.113762.1.4.1138.566)
valueset "Carotid Intervention" (2.16.840.1.113883.3.117.1.7.1.204)
valueset "Cerebrovascular Disease, Stroke, TIA" (2.16.840.1.113762.1.4.1047.44)
valueset "Diabetes" (2.16.840.1.113883.3.464.1003.103.12.1001)
valueset "End Stage Renal Disease" (2.16.840.1.113883.3.526.3.353)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "Hepatitis A" (2.16.840.1.113883.3.464.1003.110.12.1024)
valueset "Hepatitis B" (2.16.840.1.113883.3.67.1.101.1.269)
valueset "High Intensity Statin Therapy" (2.16.840.1.113883.3.526.3.1572)
valueset "Hospice Care Ambulatory" (2.16.840.1.113883.3.526.3.1584)
valueset "Hypercholesterolemia" (2.16.840.1.113762.1.4.1047.100)
valueset "Ischemic Heart Disease or Other Related Diagnoses" (2.16.840.1.113762.1.4.1047.46)
valueset "LDL Cholesterol" (2.16.840.1.113883.3.526.3.1573)
valueset "Liver Disease" (2.16.840.1.113762.1.4.1047.42)
valueset "Low Intensity Statin Therapy" (2.16.840.1.113883.3.526.3.1574)
valueset "Moderate Intensity Statin Therapy" (2.16.840.1.113883.3.526.3.1575)
valueset "Myocardial Infarction" (2.16.840.1.113883.3.526.3.403)
valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
valueset "Outpatient Consultation" (2.16.840.1.113883.3.464.1003.101.12.1008)
valueset "Outpatient Encounters for Preventive Care" (2.16.840.1.113883.3.526.3.1576)
valueset "Palliative or Hospice Care" (2.16.840.1.113883.3.600.1.1579)
valueset "Payer" (2.16.840.1.114222.4.11.3591)
valueset "PCI" (2.16.840.1.113762.1.4.1045.67)
valueset "Pregnancy or Other Related Diagnoses" (2.16.840.1.113883.3.600.1.1623)
valueset "Preventive Care Services - Established Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1025)
valueset "Preventive Care Services - Other" (2.16.840.1.113883.3.464.1003.101.12.1030)
valueset "Preventive Care Services-Individual Counseling" (2.16.840.1.113883.3.464.1003.101.12.1026)
valueset "Preventive Care Services-Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023)
valueset "Race" (2.16.840.1.114222.4.11.836)
valueset "Rhabdomyolysis" (2.16.840.1.113762.1.4.1047.102)
valueset "Stable and Unstable Angina" (2.16.840.1.113762.1.4.1047.47)
valueset "Statin Allergen" (2.16.840.1.113762.1.4.1110.42)

Data Criteria (QDM Data Elements)

"Adverse Event: Statin Allergen" using "Statin Allergen (2.16.840.1.113762.1.4.1110.42)"
"Allergy/Intolerance: Statin Allergen" using "Statin Allergen (2.16.840.1.113762.1.4.1110.42)"
"Diagnosis: Atherosclerosis and Peripheral Arterial Disease" using "Atherosclerosis and Peripheral Arterial Disease (2.16.840.1.113762.1.4.1047.21)"
"Diagnosis: Breastfeeding" using "Breastfeeding (2.16.840.1.113762.1.4.1047.73)"
"Diagnosis: Cerebrovascular Disease, Stroke, TIA" using "Cerebrovascular Disease, Stroke, TIA (2.16.840.1.113762.1.4.1047.44)"
"Diagnosis: Diabetes" using "Diabetes (2.16.840.1.113883.3.464.1003.103.12.1001)"
"Diagnosis: End Stage Renal Disease" using "End Stage Renal Disease (2.16.840.1.113883.3.526.3.353)"
"Diagnosis: Hepatitis A" using "Hepatitis A (2.16.840.1.113883.3.464.1003.110.12.1024)"
"Diagnosis: Hepatitis B" using "Hepatitis B (2.16.840.1.113883.3.67.1.101.1.269)"
"Diagnosis: Hypercholesterolemia" using "Hypercholesterolemia (2.16.840.1.113762.1.4.1047.100)"
"Diagnosis: Ischemic Heart Disease or Other Related Diagnoses" using "Ischemic Heart Disease or Other Related Diagnoses (2.16.840.1.113762.1.4.1047.46)"
"Diagnosis: Liver Disease" using "Liver Disease (2.16.840.1.113762.1.4.1047.42)"
"Diagnosis: Myocardial Infarction" using "Myocardial Infarction (2.16.840.1.113883.3.526.3.403)"
"Diagnosis: Pregnancy or Other Related Diagnoses" using "Pregnancy or Other Related Diagnoses (2.16.840.1.113883.3.600.1.1623)"
"Diagnosis: Rhabdomyolysis" using "Rhabdomyolysis (2.16.840.1.113762.1.4.1047.102)"
"Diagnosis: Stable and Unstable Angina" using "Stable and Unstable Angina (2.16.840.1.113762.1.4.1047.47)"
"Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240)"
"Encounter, Performed: Encounter for palliative care" using "Encounter for palliative care (ICD10CM Code Z51.5)"
"Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
"Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008)"
"Encounter, Performed: Outpatient Encounters for Preventive Care" using "Outpatient Encounters for Preventive Care (2.16.840.1.113883.3.526.3.1576)"
"Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1025)"
"Encounter, Performed: Preventive Care Services - Other" using "Preventive Care Services - Other (2.16.840.1.113883.3.464.1003.101.12.1030)"
"Encounter, Performed: Preventive Care Services-Individual Counseling" using "Preventive Care Services-Individual Counseling (2.16.840.1.113883.3.464.1003.101.12.1026)"
"Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up (2.16.840.1.113883.3.464.1003.101.12.1023)"
"Intervention, Order: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
"Intervention, Order: Palliative or Hospice Care" using "Palliative or Hospice Care (2.16.840.1.113883.3.600.1.1579)"
"Intervention, Performed: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
"Intervention, Performed: Palliative or Hospice Care" using "Palliative or Hospice Care (2.16.840.1.113883.3.600.1.1579)"
"Laboratory Test, Performed: LDL Cholesterol" using "LDL Cholesterol (2.16.840.1.113883.3.526.3.1573)"
"Medication, Active: High Intensity Statin Therapy" using "High Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1572)"
"Medication, Active: Low Intensity Statin Therapy" using "Low Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1574)"
"Medication, Active: Moderate Intensity Statin Therapy" using "Moderate Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1575)"
"Medication, Order: High Intensity Statin Therapy" using "High Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1572)"
"Medication, Order: Low Intensity Statin Therapy" using "Low Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1574)"
"Medication, Order: Moderate Intensity Statin Therapy" using "Moderate Intensity Statin Therapy (2.16.840.1.113883.3.526.3.1575)"
"Patient Characteristic Birthdate: Birth date" using "Birth date (LOINC Code 21112-8)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
"Procedure, Performed: CABG Surgeries" using "CABG Surgeries (2.16.840.1.113883.3.666.5.694)"
"Procedure, Performed: CABG, PCI Procedure" using "CABG, PCI Procedure (2.16.840.1.113762.1.4.1138.566)"
"Procedure, Performed: Carotid Intervention" using "Carotid Intervention (2.16.840.1.113883.3.117.1.7.1.204)"
"Procedure, Performed: PCI" using "PCI (2.16.840.1.113762.1.4.1045.67)"

Supplemental Data Elements

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Risk Adjustment Variables

None

Measure Set

None

Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Table of Contents

Population Criteria

Definitions

Functions

Terminology

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables